State of California, Department of Justice Standard Application for CCW License Z01] jAkll i. r' 2 p 3:1 Official Use Only -Typ e of Permit Requested. () Standard () Judge () Reserve Officer () 90 Day A I understand that I am obligated to be complete and truthful in providing information on this application. I that all of the information disclosed by mein this application maybe subject to, 'public disclosure. und Applicant S Thw Date Date Witness Signature / Badge Number Name: 'BORAGNO DAVID Lust JOHN Middle First If Applicable Maiden Name or-other Name(s) Used: City and County SAN FRANCISCO of Residence Date ofBirth: Country of USA Citizenship:________________________ Place of Birth: SAN FRANCISCO ' City Height: 1. Weiglit Color Byes11~ CA State Color Hair:—' Do you now have, or have you' ever had a license to carry a concealed weapon (CCW)? No 'I Yes If yes, please indicate below. Use additional pages if necessary.) Issuing Agency 2. SF County Issue Date_____________ CCW# Have you ever applied for and been denied a license to carry a concealed. weapon? No/ Yes (If yes, give agency name, date and for denial.) reason -3- State of Cnliforna, De]?n1tmeIt of 3usttce Standard Application for CCW License 3. Have ever held and subsequently renounced your United States citizenship? (111 yes, explain): No V Yes 4. If you served with the Armed Forces, were you ever convicted ofajwas your discharge other than honorable?. No 5. (If yes, explain): Are you now, or have you been a party to a lawsuit in the-last five years? No" Yes 6, :(If yes, explain): now, or have your No 7. Yes 1 Yes a restraining or(s) from any cour, If yes, explain): - Are you on probation or parole from any state for conviction of any offense including traffic? No I Yes (If yes, explain): Ma State of California, Department of Justice Standard Application for CCW License 8. Date 9. List all traffic violations (moving violations only) and motor vehicle accidents you have had in the last five years. (Else additional pages if necessary.) Have you ever been convicted for any criminal offense (civilian or military) in the U.S. or any other country? No" Yes 10. Aga / Citation# Violation /Accident (If yes, explain including date, agency, charges, and disposition.) Have you witheld any fact that might affect the decision to approve this license? No _1 Yes (If yes, explain): List below the weapons you desire to carry if granted a CCW. You may ca the weapon(s) which you list and describe herein, and only for the In I p misuse will cause an automatic revocation and possible arrest. se necessary.) Make 1 SMITH&WESSON Model 9 Caliber 357 2. 3. -5- Serial No. d only• Any i pages if t1LdJ.t( ti •...: State of California, Department nflustice Standard Application for CCW License I accept and assume all responsibility and liability for, inj-ury to, or death of any person, or damage to any property which may result through any act or omission of either the licensee or the agency that issued the lióense. In the event any claim, suit or action is brought against the agency that issued the license, its chief officer or any of its employees, by reason of, or in connection with any such act or omission, the licensee shall defend, indemnify, and hold harmless the agency that issued the license, its chief officer or any of its employees from such claim, suit, or action. I understand that the acceptance of my application by the licensing authority does not guarantee the issuance of a license and that fees and costs are not refundable if denied. I further understand that if my application is approved and I am issued a license to carry a concealed weapon, that the license is subject to ,restrictions placed upon it and that misuse of the license will cause an automatic revocation and possible arrest and that the license may also be suspended or revoked at the discretion of the licensing authority at any time. I am aware that any use of a firearm may bring criminal action or civil liability against me. I have read, understand, and agree to the CCW license liability clauses, conditions, and restrictions stated in this Application and. Agreement to Restrictions and to Hold Harmless. I have read and understand the applicable Penal Code sections regarding False Statements on a CCW Application, Manslaughter, Killing in Defense of Self or Property, Limitation on Self-defense and Defense of Property, and Child Access and Firearm Storage, stated in this application. I have read and understand Attachment 1 California Prohibiting Categories for a CCW License, Attachment 2 California Prohibiting Misdemeanors, and Attachment 3 Federal Prohibiting Categories for Possessing Firearms. I further acknowledge that these Prohibiting Categories can be amended or expanded by state or federal legislative or regulatory bodies and that any such amendment or expansion may affect my eligibility to hold a CCW. - - App cant )1V I Date Witness Signature I Badge Number Date _10- 2c\i State of California,Department of fust1ce Standard Application for CCW License Applicant Name: 13 Date of Birth: Age Social Security No.: California &ID No.:_____________ Driver's License Restrictions: c iLJE r' 3 Mailing address (if different): Number Street Apt City State Zip Apt. city state Zip Home / Personal Phone Numbers: LIS) Spouse's Name and Address:_. Applicant Occupation: Business / Employer Name:__________________ Business Phone Number: : ( Business Address: Number Street I. List all previous home addresses for the past five years. -.11- Stne of Celiforuin, Depiwtment of Justice Standard Application for CCW License 2. Have you ever been in a mental instltutj, treated for mental illness, or been found Yes (If yes, explain): not-guilty by reason of insanity? No _ • 3. _ or alcohol, or Are you now, or have you ever be&.* have you ever utilized an iigal controlled substanc7'r have you ever reported to a If yes, explain): detoxification or drug treatment program? No _Yes - ••; 4. Have yo)Yrer been involved in an incident involving firearms? No V Yes(If yes, explain: 5. Have yu been involved in a domestic violence incident? Yes No (If yes, explain): ' 6. List any arrests or formal charges, with or without disposition, for any criminal offenses With the U.S. or any other country (civilian or military). - -. State of CaUfonilu, Department of Jistiee Standard Application for CCW License If the CCW license is desired for self-protection, the protection of others, or for the protection of - large sums of money or valuable property, you are required to explain and provide good cause for issuance of the license. For example, has your life or property been threatened or jeopardized? Explain incidents and include dates, times, locations, and names of police agencies to which these incidents were reported. Details of Reason for Applicant desiring a CCW License (use additional sheets if needed). W t -4r '_c LP A cc) -13- ric, State of California, Department of Justice Standard Application for CCW License I hereby give permission to the agency to which this application is made to conduct a background investigation of me and to contact any person or agency who may add to or aid in this investigation. I further authorizb persons, firms, agencies and institutions listed on this application to release or confirm information about me and statements I have made as contained in this application. Notwithstanding any other provision of law and pursuant to the Public Reiords Act (Government Code section 6250 et seq.), I understand that information contained in this application.may be a matter of public record and shall be made available upon request or court order. I hereby .cei'tify under penalties ofeijury and Penal Code section 12051(b) and (c), that the answers I have given are -true and correct to the best of my knowledge and belief, and that I understand and agree Co the provisions, conditions, and restrictions herein or otherwise imposed. ApplicaV -M Date Witness Signature /Badge Number Date r -14- 7 •ç'